|Year : 2014 | Volume
| Issue : 1 | Page : 24-29
|Candida parapsilosis and candida guillermondii: Emerging pathogens in nail candidiasis
Felix Fich1, Alvaro Abarzúa-Araya1, Mario Pérez1, Yalile Nauhm2, Eugenia León3
1 Departament of Dermatology, Pontificia Universidad Católica de Chile, Santiago, Chile
2 Departament of Internal Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
3 Clinical Laboratory of Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
|Date of Web Publication||23-Dec-2013|
Av Vicuña Mackenna 4686, Macul, Santiago
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Onychomycosis of the fingernails and toenails is generally caused by dermatophytes and yeasts. Toenail mycoses involve mainly dermatophytes but when Candida is also involved, the strain most commonly isolated worldwide is C. albicans. Aims: To determine Candida strains prevailing in onychomycosis. Materials and Methods: A retrospective, observational and descriptive study of fungal cultures retrieved from the registry of the microbiology laboratory of the Pontificia Universidad Católica was performed. Specimens obtained from patients attending the healthcare network between December 2007 and December 2010 was analyzed. Statistical Analysis: A descriptive statistical analysis was performed. Results: Candida was retrieved from 467 of 8443 specimens (52% fingernails and 48% toenails). Cultures were negative in 5320 specimens (63.6%). Among Candida-positive cultures, parapsilosis was the most commonly isolated strain with 202 cases (43.3%). While isolates of Candida guillermondii were 113 (24.2%), those of Candida albicans were 110 (23.6%), those of spp. were 20 (4.3%) and there were 22 cases of other isolates (4.71%). Among the 467 patients with positive cultures for Candida, 136 (29,1%) were men and 331 (70,9%) were women. All patients were older than 18 years old. Clinical files were available for only 169 of the 467 patients with positive cultures for Candida. For those, age, gender, underlying illnesses and use of immunossupresive agents during the trial was reviewed. Conclusions: The present study shows that both C. parapsilosis as well as C. guillermondii appear as emerging pathogens that would be in fact taking the place of C. albicans as the most commonly isolated pathogen in patients with Candida onychomycosis. The relative percentage of C parapsilosis increases every year. Identification of Candida strains as etiological agents of nail candidiasis becomes relevant to the management both nail as well as systemic candidiasis, in view of the resistance to conventional treatments readily reported in the literature.
Keywords: Candida, guillermondi, onychomycosis, parapsilosis
|How to cite this article:|
Fich F, Abarzúa-Araya A, Pérez M, Nauhm Y, León E. Candida parapsilosis and candida guillermondii: Emerging pathogens in nail candidiasis. Indian J Dermatol 2014;59:24-9
|How to cite this URL:|
Fich F, Abarzúa-Araya A, Pérez M, Nauhm Y, León E. Candida parapsilosis and candida guillermondii: Emerging pathogens in nail candidiasis. Indian J Dermatol [serial online] 2014 [cited 2021 Jun 24];59:24-9. Available from: https://www.e-ijd.org/text.asp?2014/59/1/24/123485
What was known?
Toenail mycoses involve mainly dermatophytes but when Candida is also involved, the strain most commonly isolated worldwide is C albicans.
| Introduction|| |
Approximately 20% of individuals aged between 40 and 60 have onychomycosis. , Three main groups of fungi are involved: dermatophytes, yeasts of the Candida genus and molds.
The role of Candida species in the production of onychomycosis has been largely discussed. Over years, nail candidiasis was considered only as those cases related to hand paronychia. Progress in mycology has finally recognized candida's ability to invade the nail plate and cause nail disorders indistinguishable from those generated by dermatophytes.
Candida albicans and Candida parapsilosis, among others, may be commensals and be part of the skin normal flora; however in immunodeficiency settings they are able to cause severe systemic infections. Systemic infections caused by Candida albicans are widely known, but Candida parapsilosis is emerging as culprit for severe infections among inpatients.  In a 10-year-study conducted in Texas, C. glabrata was associated to candidemia in patients with hematological malignancies, favored by neutropenia. C. parapsilosis was associated to the use of central venous catheters, a finding in accordance with the reports of Warnock. , C. tropicalis is emerging as an important pathogen in neutropenic patients and C. parapsilosis is doing so among patients receiving transparentheral nutrition. C. glabrata and C. krusei have rapidly developed resistance to fluconazole. 
In general it is accepted that patients undergoing nail candidiasis must have an intercurrent disease able to cause immunosuppression. Among the latter are HIV/AIDS, diabetes, circulation disorders, connective tissue diseases and prolonged immunosuppressive therapy with cytostatics or steroids. However, various recent studies have demonstrated the role of Candida in the generation of onychomycosis without referring to underlying causes, where Candida has been responsible for a very variable percentage of onychomycosis, between 3,5 and 58,5%. ,,,,
When nail candidiasis associates to fingernail paronychia, particularly in women who keep their hands under soapy water for long periods of time, clinical diagnosis is simple and mycological exam just confirms a clinical suspicion. The case of toenail onychomycoses, either distal-lateral subungual or total dystrophic forms, is different. In such cases, the finding of Candida in a mycologic test must meet certain requirements for Candida to be considered the causal agent.
Recently, Candida is coming into sight as an important cause of onychomycosis, as confirmed by studies from India and Spain, where their authors are proving that Candida is the main cause of onychomycosis in their geographical location. , In an American study involving eleven states between 1997 and 2002, Candida was responsible for 70% of onychomycoses, especially in cases affecting fingernails. 
Internationally, there is not one common criterion to attribute the etiology of onychomycoses to Candida. The analysis of various works shows that methods differ in the number of inocula required to be positive. There are also differences in whether the repetition of the test twice or more is required to attribute the cause of the nail affection to a non-dermatophyte fungus.
Walshe and English criteria for the diagnosis of molds in onychomycoses, proposed in 1966, refer to the number of nail fragments positive for the suspected fungus. Five or more than twenty inocula in the absence of dermatophytes and a compatible direct test would be enough to make an etiologic diagnosis.  However, in 2001 Gupta et al. demonstrated that such method issued the correct diagnosis only in 23.2% of the cases. 
The prevalence of Candida onychomycoses and the species more commonly involved are a key issue to assess. As previously stated, the review of current works shows that the epidemiology of Candida onychomycosis is different depending on the geographical location. Undoubtedly, the most commonly reported species is albicans, both among adults and children. ,,,, however, the emergence of other species in various sites of the world is pointing towards a change in epidemiological behavior of the disease: C. krusei, C. glabrata, C. parapsilosis and C. tropicalis in India and Singapore. , C. tropicalis and C. guillermondii in Malta.  C. parapsilosis, C. tropicalis and C. guillermondii in Brazil.  C. parapsilosis, C. albicans and C. glabrata in Mexico,  C. guillermondii and C. albicans in Germany,  and C. tropicalis, C. albicans, C. glabrata and C. krusei in Turkey.  In Sao Paulo nail candidiasis outnumbered nail dermatophytosis, with C. albicans and C. parapsilosis being found more commonly, in the same order, particularly in fingernail onychomycosis.  Among the isolated species of Candida there are some resistant to various commonly used antifungals, such as Candida glabrata which is resistant to imidazoles. 
Our objective was to evaluate the presence of various Candida species in Candida onychomycosis, and to assess their relative significance, in order to either confirm the need to modify our management protocols or to continue with therapies currently used.
| Materials and Methods|| |
A retrospective, observational and descriptive study of 8443 fungal cultures was performed. Mycological cultures taken within the health network of Pontificia Universidad Católica and concentrated at the Laboratory of the Centro Médico San Joaquín were reviewed. The three year analysis period included specimens from December 2007 to December 2010. Specimens of nails were collected scrapping the surface of the nail plates to perform a direct microscopy study after treatment with 20% potassium hydroxide and were seeded on Sabouraud glucose agar with the addition of chloramphenicol and lactrimel agar, for 25 days incubation at 30°C, with periodic revision and observation. Yeast identification was achieved with the germinative tube test and through commercial tests of the API ID 32C system, BioMerieux (France), as per manufacturer's specifications.
The strains ATCC 90028 (Candida albicans), ATCC 9968 (Candida tropicalis) and ATCC 64677 (Candida glabrata) were used as controls. ,
Wherever available, files of patients who had a positive culture for Candida were analyzed for clinical information like their age, gender, underlying illnesses and/or use of immunosuppressive agents during the trial.
A descriptive statistical analysis was performed, because we have included all the specimens obtained from patients attending the healthcare network between December 2007 and December 2010. We have not excluded any of them from the study.
| Results|| |
A total of 8443 nail specimens were analyzed. Of the total of specimens analyzed, 3123 were positive (36.9%). Candida grew in 467 specimens (15%), of which 223 were from toenails (47.8%) and 244 from fingernails (52.2%) [Table 1]. The isolated Candida species were mainly C. parapsilosis, in 202 cases (43.3%), C. guillermondii in 113 (24,2%) and C. albicans in 110 cases (23,6%). Together the 3 strains represented 91.1% of all Candida detections.
Dermatophytes were isolated from 2637 specimens and they accounted mainly for T. rubrum (88,2%) and T. mentagrophytes (11.6%) [Table 2]. Molds were isolated from 18 specimens, with Fusarium sp being the most common, accounting for 61% of mold isolates [Table 3]. When analyzing the proportion of Candida species per year, an increase of C. parapsilosis in 25.62% is evidenced [Table 1].
Among the 467 patients with positive cultures for Candida, 136 (29,1%) were men and 331 (70,9%) were women. All patients were older than 18 yrs old. Clinical files were available for only 169 of the 467 patients with positive cultures for Candida. For those patients, age, gender, underlying illnesses and use of immunossupresive agents during the trial were reviewed. Among those patients, 14 (8%) had type 2 diabetes, 11 (7%) connective tissue disorders, 9 (5%) psoriasis, 3 (2%) inflammatory bowel disease, 1 (1%) HIV, 1 (1%) hepatic cirrhosis and 1 (1%) Ewing Sarcoma. 13 (8%) of the patients who were suffering underlying illnesses where receiving immunosuppressive therapy with prednisone, methotrexate or azathioprine, for more than a year.
| Discussion|| |
The analysis of results revealed that, Candida represents 15% of all studied onychomycoses, and that it affected fingernails and toenails with similar rates.
The results of Chilean studies reported in 1981 showed that Candida accounted for 25.6% of all onychomycoses, those reported in 1987 evidenced that Candida accounted for 51% of all onychomycoses. , It is worth noting that in occasions, Candida presents as the only agent and in others it is a concomitant agent together with molds or dermatophytes. The coexistence of a dermatophyte with yeasts or molds in the mycological test, is very indicative of a dermatophyte as the real culprit for the problem. 
Gender is also a factor that has an impact on results, since Candida is more common in women who permanently get their hands wet. Such circumstances might explain the differences seen in different studies, where proportions of specimens from women and men differ.
In our work, the most striking fact is the predominance of C. parapsilosis, accounting for 43.3% of the cases studied, and that is twice as frequent as C. guillermondii and C. albicans. That the proportion of C. parapsilosis in nails increases in a sustained manner between 2008 and 2010, while C. albicans and C. guillermondii do not follow such a growth curve and stay in relatively stable proportions, is striking [Figure 1].
We could also infer that most of the patients with nail candidiasis do not present comorbidities which could alter their host immunity, as has been described in the literature and that coincides with foreign publications. However, a clinical evaluation is recommended in patients with candida infection.
It is very common to see that in published reports mycology analyses of the skin and adnexae just refer to C. albicans and C. spp. Because mycosis epidemiology is a constantly evolving phenomenon, nail candidiasis caused by species other than albicans might be expected to have a role as a gateway to systemic candidiasis, thus implying an additional concern for clinical and therapeutic aspects.
An oncology institute in Slovakia reported C. krusei, C. parapsilosis, C. glabrata, C. tropicalis and C. guillermondii fungaemia over 10 years, there were 45 non-albicans C. fungaemias as compared to 75 C. albicans fungaemias. 
Candida fungaemia behavior has been changing in time. In Slovakia, until 1990, non-albicans Candida accounted for 10-40% of all candidemias, while between 1991-1998 it accounted for 35-65%. The most common species were C. parapsilosis, C. tropicalis and C. glabrata. Remarkably, C. krusei and C. glabrata were resistant to fluconazole and C. lusitaniae and C. rugosa were resistant to amphotericin B. 
Non-albicans Candida incidence has proved to be higher than that of C. albicans (54.4% vs. 45.6%). While C. krusei relates to the prior use of antifungals, hematological malignancies, neutropenia, stem-cell transplant and steroid therapy,  C. parapsilosis has been associated to endocarditis in intravenous drug abusers and nosocomial infections such as septic arthritis, peritonitis and endophthalmitis and invasive medical instrumentation. Between 1989 and 1992, C. krusei was responsible for 5% of fungaemias in Houston, and between 1993-1996 such figure increased to 10%. It presented especially among patients with leukemia and C. albicans related to catheter use. In neutropenic patients, C. krusei was associated to higher mortality rates (49%) than C. albicans (28%). 
The frequency of C. parapsilosis in nosocomial infections related to skin colonization, particularly the subungual space and oral cavity, has increased. In Taiwan, from a group of 323 healthy volunteers, 15.2% had oral cavity colonization by Candida, with C. albicans accounting for 57.7% and C. parapsilosis accounting for 15.4% of cases. 
The sensitivity of various Candida species varies in different countries. A decrease in the susceptibility of C. parapsilosis to amphotericin B, 5-fluorocytosine but a good susceptibility to imidazole drugs have been reported. ,
A study conducted in Venezuela with inpatients, revealed different Candida species have different susceptibility to the different antimycotic drugs. C. albicans showed sensitivity to fluconazole in 92.6%, C. tropicalis in 87.1% and C. glabrata in 56.7%. Also, all the studied strains were sensitive to amphotericin B and voriconazole.  Another study reveals that C. krusei and C. glabrata are poorly sensitive to fluconazole and the resistance increase is suggested to be a consequence of the frequent prophylactic use of fluconazole.  The association between non-albicans species has been observed in Japan in fluconazole-related candidemias. While C. tropicalis, C. parapsilosis and C. guillermondii were sensitive to therapy, C. glabrata and C. krusei were less sensitive. Moreover, C. parapsilosis and C. guillermondii had a high minimal inhibitory concentration (MIC) for micafungin. 
In Kuwait, the species most commonly isolated from blood cultures was C. albicans (39,5%) as opposed to C. parapsilosis that was isolated from 30,6% of the cases. Interestingly, all the strains were sensitive to voriconazole and resistance to amphotericin B and fluconazole was persistently low, in spite of the routine use of such drugs in systemic candidiasis.  Authors suggest the use of voriconazole to treat infections caused by fluconazole and itraconazole - resistant yeast. 
With regard to cell wall inhibitors such as echinocandins, C. albicans has also been revealed as the most sensitive species, while C. glabrata, C. tropicalis and C. krusei are less sensitive; C. parapsilosis and C. guillermondii are intrinsically resistant by virtue of specific mutations. 
A study published in Spain revealed the best MIC of amphotericin B for C. albicans, higher than the MIC obtained for C. tropicalis, C. glabrata and C. parapsilosis. 
In vitro sensitivity of various Candida species to various polyene formulations (amphotericin, nystatin) and itraconazole revealed seldom differences between themselves. However, sensitivity to polyenes is superior than sensivity to fluconazole. 
There is evidence that terbinafine has good therapeutic results in C. parapsilosis, but not in other species of Candida; this could lead to the conclusion that terbinafine may be useful in the treatment of nail candidiasis adding a new therapeutic tool. ,
To date there are no evidences of a literature reference showing the results presented herein concerning the proportional increase of C. parapsilosis in nail candidiasis. It is worth noting that the works published do not express rates but simple percentages since studies do not involve a defined assigned population. Laboratories receive specimens from all centers without considering specific populations. Moreover, they refer to the consulting population, thus inducing a bias.
In the future, we should assess the prevalence of onychomycosis in the general population to really appreciate the magnitude of this public health issue.
| References|| |
|1.||Jayatilake JA, Tilakaratne WM, Panagoda GJ. Candidal onychomycosis: A mini-review. Mycopathologia 2009;168:165-73. |
|2.||DAS S, Goyal R, Bhattacharya SN. Laboratory-based epidemiological study of superficial fungal infections. J Dermatol 2007;34:248-53. |
|3.||Weems JJ Jr. Candida parapsilosis: Epidemiology, Pathogenicity, Clinical Manifestations, and Antimicrobial Susceptibility. Clin Infect Dis 1992;14:756-66. |
|4.||Hachem R, Hanna H, Kontoyiannis D, Jiang Y, Raad I. The changing epidemiology of invasive candidiasis: Candida glabrata and candida krusei as the leading cause of candidemia in hematologic malignancy. Cancer 2008;112:2493-9. |
|5.||Warnock DW. Azole drug resistance in Candida species. J Med Microbiol 1992;37:225-6. |
|6.||Gupta AK, Jain HC, Lynde CW, Mac Donald P, Cooper EA, Summerbell RC. Prevalence and epidemiology of onychomycosis in patients visiting physicians' offices: A multicenter Canadian survey of 15000 patients. J Am Acad Dermatol 2000;43:244-8. |
|7.||Veer P, Parwardhan NS, Damle AS. Study of onichomycosis: Prevailing fungi and pattern of infection. Indian J Medical Microbiol 2007;25:53-6. |
|8.||Gupta AK, Cooper EA, MacDonald P, Summerbell RC. Utility of Inoculum Countin (Walshe and English Criteria) in Clinical Diagnosis of Onychomycosis Caused by Nondermatophytic Filamentous Fungi. J Clin Microbiol 2001;39:2115-21. |
|9.||Wade Foster K, Ghannoum MA, Elewski B. Epidemiologic surveillance of cutaneous fungal infection in the United States from 1999 to 2002. J Am Acad Dermatol 2004;50:748-52. |
|10.||Vélez A., Linares MJ, Fernandez-Roldán JC, Casal M. Study of onychomycosis in Córdoba, Spain: Prevailing fungi and pattern of infection. Mycopathologia 1997;137:1-8. |
|11.||Walshe MM, English MP. Fungi in nails. Br. J. Dermatol 1966;78:198-207. |
|12.||Lange M, Roszkiewicz J, Szczerkowska-Dobosz A, Jasiel-Walikowska E, Bykowska B. Onychomycosis is no longer a rare finding in children. Mycoses 2006;49:55-9. |
|13.||Aghamirian MR, Ghiasian SA. Onychomycosis in Iran: Epidemiology, Causative Agents and Clinical Features. Jpn J Med Mycol 2010;51:23-9. |
|14.||Romano C, Gianni C, Difonzo EM. Restrospective study of onychomycosis in Italy: 1985-2000. Mycoses 2005;48:42-4. |
|15.||Alvarez MI, González LA, Castro LA. Onychomycosis in Cali, Colombia. Mycopathologia 2004:158:181-6. |
|16.||Kwok YK, Thai YK, Goh CL, Kamarudin A, Koh MT, Seow CS. Epidemiology and in vitro activity of antimycotics against candidal vaginal/skin/nail infections in Singapore. Int J Dermatol 1998;37:145-9. |
|17.||Vella Zahra L, Gatt P, Boffa MJ, Borg E, Mifsud E, Scerri L, et al. Characteristics of superficial mycoses in Malta. Int J Dermatol 2003;42:265-71. |
|18.||Figueiredo VT, de Assis Santos D, Resende MA, Hamdan JS. Identification and in vitro antifungal susceptibility testing of 200 clinical isolates of Candida spp. responsible for fingernail infections. Mycopathologia 2007;164:27-33. |
|19.||Manzano-Gayosso P, Méndez-Tovar LJ, Arenas R, Hernández-Hernández F, Millán-Chiu B, Torres-Rodriguez JM, et al. Levaduras causantes de onicomicosis en cuatro centros dermatológicos mexicanos y se sensibilidad antifúngica a compuestos azólicos. Onicomicosis por levaduras. Rev Iberoam Micol 2011;28:32-5. |
|20.||Mügge C, Haustein UF, Nenoff P. Causative agents of onychomycosis-a retrospective study. J Dtsch Dermatol Ges 2006;4:218-28. |
|21.||Ilkit M. Onychomycosis in Adana, Turkey: A 5-year study. Int J Dermatol 2005;44:851-4. |
|22.||Godoy-Martínez P, Nunes FG, Tomimori-Yamashita J, Urrutia M, Zaror L, Silva V, et al. Onychomycosis in Sao Paulo, Brazil. Mycopathologia 2009;168:111-6. |
|23.||Lynne S. García, Clinical Microbiology Procedures Handbook. Vol. 2. Washington DC: ASM press 2010. |
|24.||Murray P, Baron EJO, Jorgensen JH, Landry ML, Pfaller MA. Manual of Clinical Microbiology. 9 th ed. Vol. 2. Washington DC: ASM press 2007. |
|25.||Fich F, Díaz MC, Moreno MI, Salamanca L. Superficial dermatomycoses. Study of patients at the Central Santiago Metropolitan Health Service. Rev Med Chile 1981;109:735-9. |
|26.||Díaz MC, Fich F, Salamanca L, Hering M. Variaciones en la etiología de las micosis superficiales en dos servicios hospitalarios de la región metropolitana. Rev Méd Chile 1987;115:319-22. |
|27.||Gupta AK. Ryder JF, Summerbell RC. The diagnosis of non-dermatophyte mold onychomycosis. Int J Dermatol 2003;42:272-3. |
|28.||Krcmery V Jr, Mrazova M, Kunova A, Grey E, Mardiak J, Jurga L, et al. Nosocomial candidaemias due to species other than Candida albicans in cáncer patients. Aetiology, risk factors, and outcome of 45 episodes within 10 years in a single cancer institution. Support Care Cancer 1999;7:428-31. |
|29.||Kromery V, Barnes AJ. Non-albicans Candida spp causing fungaemia: Pathogenicity and antifungal resistance. J Hospital Infect 2002;50:243-60. |
|30.||Horn DL, Neofytos D, Anaissie EJ, Fishman JA, Steinbach WJ, Olyaei AJ, et al. Webster. Epidemiology and outcomes of candidemia in 2019 patients: Data from the prospective antifungal therapy alliance registry. Clin Infect Dis 2009;48:1695-703. |
|31.||Abbas J, Bodey GP, Hanna HA, Mardani M, Girgawy E, Abi-Said D, et al. Candida krusei fungemia. Arch Intern Med 2000;160:2659-64. |
|32.||Yang YL, Leaw SN, Wang AH, Chen HT, Cheng WT, Lo HJ. Characterization of yeasts colonizing in healthy individuals. Med Mycol 2011;49:103-6. |
|33.||Seidenfeld SM, Cooper BH, Smith JW, Luby JP, Mackowiak PA. Amphotericin B. tolerance: A characteristic of Candida parapsilosis not shared by other Candida species. J Infect Dis 1983;147:116-9. |
|34.||Lombardi G, Gramegna G, Cavanna C, Poma G, Marangoni E, Michelone G. Itraconazole vs amphotericin B: In vitro comparative evaluation of the minimal inhibitory concentration (MIC) against clinically isolated yeasts. Mycopathologia 1989;106:31-4. |
|35.||Dolande Franco ME, Reviakina V, Panizo MM, Macero C, Moreno X, Calvo A, et al. Distribución y sensibilidad a los antifúngicos de aislamientos clínicos de Candida en seis centros de salud del área metropolitana de Caracas, Venezuela (años 2003-2005). Rev Iberoam Micol 2008;25:17-21. |
|36.||García Ruiz JC. Micosis en los pacientes hematológicos. Rev Iberoam Micol 2002;19:13-6. |
|37.||Myoken Y. Clinical pathogenesis of candidemia caused by non-albicans Candida species. Nippon Ishinkin Gakkai Zasshi 2009;50:225-8. |
|38.||Mokaddas EM, Al-Sweih NA, Khan ZU. Species distribution and antifungal susceptibility of Candida bloodstream isolates in Kuwait: A 10-year study. J Med Microbiol 2007;56:255-9. |
|39.||Swinne D, Watelle M, Nolard N. In vitro activities of voriconazole, fluconazole, itraconazole and amphotericin B against non Candida albicans yeast isolates. Rev Iberoam Micol 2005;22:24-8. |
|40.||Walker LA, Gow NA, Munro CA. Fungal echinocandin resistance Fungal Genet Biol 2010;47:117-26. |
|41.||Cantón E, Pemán J, Viudes A, Quindós G, Gobernado M, Espinel-Ingroff A. Minimum fungicidal concentrations of amphotericin B for bloodstream Candida species. Diag Microbiol Infect Dis 2003;45:203-6. |
|42.||Carrillo-Muñoz AJ, Quindós G, Tur C, Ruesga MT, Miranda Y, del Valle O, et al. In vitro antifungal activity of liposomal nystatin in comparison with nystatin, amphotericin B cholesteryl sulphate, liposomal amphotericin B, amphotericin B lipid complex, amphotericin B desoxycholate, fluconazole and itraconazole. J Antimicro Chemother 1999;44:397-401. |
|43.||Gupta AK, Sauder DN, Shear NH. Antifungal agents: An overview. Part II. J Am Acad Dermatol 1994;30:911-33 |
|44.||Nolting S, Brautigam M, Weidinger G. Terbinafine in onychomycosis with involvement by non-dermatophytic fungi. Br J Dermatol 1994;130:16-21. |
What is new?
1. The present study shows that both C. parapsilosis as well as C. guillermondii appear as emerging pathogens that would be in fact taking the place of C. albicans as the most commonly isolated pathogen in patients with Candida onychomycosis.
2. Identification of Candida strains as etiological agents of nail candidiasis becomes relevant to the management both nail as well as systemic candidiasis, in view of the resistance to conventional treatments readily reported in the literature.
[Table 1], [Table 2], [Table 3]
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